Questionnaire to Evaluate Behaviors of Old DogsClient Name* First Last Pet's Name*This section of the history form is to be completed only if your dog is older (> 7 years for larger dogs and > 10 years for smaller ones) so that we can assess changes associated with aging. If your dog is not elderly or you have no complaints that could be associated with age, you do not have to complete this form. If you are uncertain, please complete the form.1. Locomotory/ambulatory assessment (select only one) No alterations or debilities noted Modest slowness associated with change from youth to adult Moderate slowness associated with geriatric aging Moderate slowness associated with geriatric aging plus alteration or debility in gait Moderate slowness associated with geriatric aging plus some loss of function (e.g., cannot climb stairs) Severe slowness associated with extreme loss of function, particularly on slick surfaces (may need to be carried) Severe slowness, extreme loss of function, and decreased willingness or interest in locomoting (spends most of time in bed) Paralyzed or refuses to move 2. Appetite assessment (may select more than one) No alterations in appetite Change in ability to physically handle food Change in ability to retain food (vomits or regurgitates) Change in ability to find food Change in interest in food (may have to do with their ability to smell) Change in rate of eating Change in completion of eating Change in timing of eating Change in preferred textures 3. Assessment of elimination frequency and “accidents” (select only one) No change in frequency and no "accidents" Increased frequency, no "accidents" Decreased frequency, no "accidents" Increased frequency with "accidents" Decreased frequency with "accidents" No change in frequency, but "accidents" 4. Assessment of Bladder Control (select only one) Leaks urine when asleep, only Leaks urine when awake, only Leaks urine when awake or asleep Full-stream, uncontrolled urination when asleep, only Full-stream, uncontrolled urination when awake, only Full-stream, uncontrolled urination when awake or asleep No leakage or uncontrolled urination, all urination controlled, but in inappropriate or undesirable location No change in urination control or behavior 5. Assessment of Bowel Control (select appropriate answer if this occurs)Defecates when asleep Formed Stool Diarrhea Mixed Defecates without apparent awareness Formed Stool Diarrhea Mixed Defecates when awake but undesirable or inappropriate areas Formed Stool Diarrhea Mixed No changes in bowel control No changes in bowel control 6. Visual acuity-how well do you think the dog sees? (select only one) No change in visual acuity detected – appears to see as well as ever Some change in acuity not dependent on ambient light conditions Some change in acuity dependent on ambient light conditions Extreme change in acuity not dependent on ambient light conditions Extreme change in acuity dependent on ambient light conditions Blind 7. Auditory acuity-how well do you think the dog hears? (select only one) No apparent change in auditory acuity Some decrement in hearing-not responding to sounds to which the dog used to respond Extreme decrement in hearing-have to make sure the dog is paying attention or repeat signals or go get the dog when called Deaf-no response to sounds of any kind 8. Play interactions-if the dog plays with toys (other pets are addressed later), which situation best describes that play? (select only one) No change in play with toys Slightly decreased interest in toys, only Slightly decreased ability to play with toys, only Slightly decreased interest and ability to play with toys Extreme decreased interest in toys, only Extreme decreased ability to play with toys, only Extreme decreased interest and ability to play with toys 9. Interactions with humans-which situation best describes that interaction? (select only one) No change in interaction with people Recognizes people but slightly decreased frequency of interaction Recognizes people but greatly decreased frequency of interaction Withdrawal but recognizes people Does not recognize people 10. Interactions with other pets- which situation best describes that interaction? (select only one) No change in interaction with other pets Recognizes other pets but slightly decreased frequency of interaction Recognizes other pets but greatly decreased frequency of interaction Withdrawal but recognizes other pets Does not recognize other pets No other pets or animal companions in house or social environment 11. Changes in sleep/wake cycle (select only one) No changes in sleep patterns Sleeps more in day, only Some change-awakens at night and sleeps more in day Much change-profoundly erratic nocturnal pattern and irregular daytime pattern Sleeps virtually all day, awake occasionally at night Sleeps almost around the clock 12. Is there anything else you think we should know?
